Transforaminal Endoscopic Lumbar Discectomy for L5-S1 Disc Herniation With High Iliac Crest: Technical Note and Preliminary Series

Comparison of Full Endoscopic Lumbar Diskectomy Using the Transforaminal Approach versus Interlaminar Approach for L5-S1 Lumbar Disk Herniation Treatment: A Meta-Analysis

BACKGROUND

 Numerous studies have examined the clinical effectiveness of transforaminal full endoscopic lumbar diskectomy (T-FELD) and interlaminar full endoscopic lumbar diskectomy (I-FELD) for L5-S1 lumbar disk herniation (LDH), with mixed findings. The goal of this systematic review and meta-analysis was to evaluate the perioperative outcomes, clinical results, and complications of T-FELD and I-FELD to determine their efficacy and safety for treating L5-S1 LDH and to examine the features of complications in depth.

METHODS

 Several databases were searched for articles that matched all of the inclusion criteria. The visual analog scale (VAS) and Oswestry Disability Index (ODI) were used to assess the clinical results. Information on perioperative outcomes and complications was gathered and analyzed.

RESULTS

 Eight studies with 756 participants were included. There were no significant differences in postoperative bed time (p = 0.44) and hospitalization time (p = 0.49) between T-FELD and I-FELD. When compared with I-FELD, T-FELD was associated with substantially longer fluoroscopy time (p < 0.0001) and operating time (p < 0.0001). There were no significant differences in the preoperative and postoperative VAS and ODI scores between T-FELD and I-FELD. The rates for overall complications, postoperative dysesthesia, postoperative lower extremity pain, incomplete decompression, recurrence, and conversion to open surgery were comparable for T-FLED and I-FELD.

CONCLUSION

 T-FELD and I-FELD had equal clinical results and safety for treatment of L5-S1 LDH. Fluoroscopy and operative times were shorter for I-FELD than for T-FELD.

Transforaminal lumbar endoscopic discectomy: should we abandon it for L5-S1 foraminal and extraforaminal lumbar disc herniations? A prospective non-randomised study and literature review

PURPOSE

The aim of this study is to investigate the clinical outcomes of transforaminal lumbar endoscopic discectomy (TLED) in patients with L5-S1 lumbar disc herniation (LDH).

MATERIALS AND METHODS

Seventy-five consecutive individuals with diagnosed foraminal/extraforaminal L5-S1 LDH were included in this study. All patients underwent TLED, being subsequently evaluated in a 2-year follow-up period. Assessment was performed preoperatively and at 6 weeks and 3, 6, 12 and 24 months postoperatively. Visual Analogue Scale (distinctly applied for lower limb - VAS-LP and low back - VAS-BP pain) and Short-Form 36 (SF-36) Medical Health Survey Questionnaire were implemented to assess pain and health-related quality of life (HRQoL) of enrolled individuals, respectively.

RESULTS

No major perioperative complications were observed. Recorded values of all studied indices were demonstrated to feature a clinically and statistically significant amelioration at 6 weeks, presenting lesser improvement at 3 months with subsequent stabilisation. VAS-LP and VAS-BP values were displayed to reach a plateau in 6 months postoperatively, whereas all parameters of SF-36 continued to present a statistically significant improvement until the end of follow-up at 2 years.

CONCLUSIONS

TLED represent a safe and efficient technique in terms of diminishing perceived pain and improving HRQoL in patients with L5-S1 LDHs. However, specific patient- and technique-related circumstances on the ground of low surgical experience may limit its effectiveness in these patients.

Repeat Surgery after Percutaneous Endoscopic Lumbar Discectomy for Adolescent Lumbar Disc Herniation: A Multicenter Observational Study

OBJECTIVE

The reported date in the repeat surgical intervention for adolescent lumbar disc herniation (ALDH) after percutaneous endoscopic lumbar discectomy (PELD) was quite scarce. This study aims to introduce cases of repeat surgeries after PELD for ALDH and assess the incidence, chief causes, repeat surgery methods, and surgical outcomes of repeat surgeries after PELD for ALDH.

METHODS

A retrospective multicenter observational study was conducted on patients undergoing repeat surgeries after PELD for ALDH at four tertiary referral hospitals from January 2014 through August 2022. The incidence of repeat surgeries, chief causes, strategies for repeat surgeries, and timing of repeat surgeries were recorded and analyzed. The clinical outcomes were evaluated by the Numeric Rating Scales (NRS) scores and the modified MacNab criteria. Statistical analyses were performed with the Wilcoxon signed-rank test.

RESULTS

A total of 23 patients who underwent repeat surgeries after PELD for ALDH were included. The chief causes were re-herniation (homo-lateral re-herniation at the same level, new disc herniation of adjacent level). The repeat surgery methods were revision PELD, micro-endoscopic discectomy (MED), open discectomy and instrumented lumbar inter-body fusion. The NRS scores decreased significantly in follow-up evaluations and these scores demonstrated significant improvement at the last follow-up (p < 0.002). For the modified MacNab criteria, at the last follow-up, 18 patients (78.26%) had an excellent outcome, and the overall success rate was 86.95%.

CONCLUSION

This study's data suggest that young patients who underwent repeat surgery improved significantly compared to baseline. The chief cause was re-herniation. Revision PELD was the main surgical procedure, which provides satisfactory clinical results in young patients who underwent repeat surgeries.

Transforaminal endoscopic lumbar discectomy using a 45° puncture angle and foraminotomy versus traditional THESYS for L5/S1 lumbar disc herniation: a prospective randomized controlled trial

PURPOSE

Prospective comparison of the efficacy and safety of transforaminal endoscopic lumbar discectomy (TELD) with a 45° puncture angle versus traditional Thomas Hoogland endoscopy spine systems (THESYS) for the surgical treatment of L5/S1 lumbar disc herniation (LDH).

METHODS

Consecutive patients with L5/S1 LDH who underwent TELD were randomized (1:1) assigned to the 45° TELD group and the THESYS group. Clinical outcomes were assessed at pre-operation, 1-day and 3/6-months post-operation till final follow-up. Surgical-related parameters, visual analogue scale (VAS) score, oswestry disability index (ODI), and modified MacNab criteria, and surgical complications were recorded and analysed.

RESULTS

All patients were followed up for at least 24 months. Compared to the THESYS group, the 45° TELD group had a shorter operative time (P < 0.001) and intraoperative radiation time (P < 0.001) and a smaller VAS score for back pain (P < 0.001) and leg pain intraoperatively (P < 0.001). The VAS and ODI in the 45° TELD group were significantly better than those in the THESYS group within 3 months postoperatively. However, from 3 months on, both groups showed comparable VAS and ODI. There was no significant difference between the two groups of modified MacNab criteria. There were two cases of residual disc and two cases of recurrence that required reoperation in the THESYS group.

CONCLUSION

For L5/S1 LDH, the 45° TELD technique was superior to traditional THESYS in terms of surgery-related parameters and faster improvement of VAS and ODI, with a lower complication rate.

Global Trends and Hotspots of Minimally Invasive Surgery in Lumbar Spinal Stenosis: A Bibliometric Analysis

Objective

The popularity of minimally invasive surgery for lumbar spinal stenosis (LSS) has been steadily increasing worldwide. This study aims to conduct a comprehensive bibliometric analysis to identify global trends and hotspots in the research related to this surgical approach.

Methods

Select articles related to the field that were retrieved from the Web of Science Core Collection (WoSCC) between January 1, 1993 and December 31, 2022. Visualization of networks and in-depth bibliometric analyses, including the number of publications, countries/regions, institutions, journals, authors, keywords, and references, were conducted using VOSviewer and CiteSpace software.

Results

A total of 1197 papers were identified over a three-decade period, with the highest production year being 2022, which saw 171 papers published. The most prolific countries/regions were the United States (279) and Harvard Medical School (59). Among journals, Spine (3289 citations) was the most cited, while World Neurosurgery (98 publications) had the highest number of publications. Lewandrowski, Kai-Uwe (29 publications) wrote the most articles, and Ahn, Y (239 citations) ranked first among cited authors. The most frequently used keyword was "discectomy", but recent years have shown a strong emergence of keywords such as "microendoscopic decompressive laminotomy", "foraminotomy" and "classification".

Conclusion

The United States and China have emerged as leaders in the field of minimally invasive surgery for LSS. Endoscopic spinal surgery is recognized as a critical approach, with ongoing research focused on indications, potential complications, minimally invasive anatomical approaches, and outcomes. Furthermore, there is a strong emphasis on optimizing the surgical process, which has become a trending and hot spot in current research. The improvement of surgical techniques is at the forefront of advancements in this field.

Near infrared imaging system for preventing blood vision obstruction in endoscopy

Spinal endoscopy procedure is commonly used in the diagnosis and treatment of various health problems and is effective. Bleeding is one of the most common complications of spinal endoscopy procedures. Blood vision obstruction (BVO), that is, obstruction of the endoscopic camera lens caused by the accumulation of blood in the surgical field, is a serious problem in endoscopic procedures. This study presents what we believe to be a new approach to addressing BVO with external multispectral imaging. The study was completed using a BVO simulation model, and the results reveal that this technology can be used to effectively overcome BVO and provide clear images of the anatomy, enabling more effective diagnosis and treatment. This technique may enable improvement of the outcomes of endoscopic procedures and could have far-reaching implications in the field of endoscopy.

A retrospective cohort study on the significance of preoperative radiological evaluation of lumbar degenerative diseases for surgical reference

Background

Radiography has low radiation exposure and the ability to acquire information. Due to its cost-effectiveness and availability, preoperative radiographic imaging examination is considered to be a valuable method to evaluate the condition of patients with spinal disease. The aim of this cohort study is to analyze the impact of evaluating preoperative X-rays on the surgical management of lumbar degenerative diseases (LDD).

Methods

We reviewed 49 patients with LDD underwent single-level posterior instrumented lumbar fusion (PILF) between November 2017 and October 2022 in this cohort study. The median iliac angle (MIA), iliac crest height, intervertebral facet joint degeneration, lumbosacral angle (LSA), L5/S1 intervertebral space angle (ISA), intervertebral foramen height (IFH) and intervertebral space height (ISH) were measured on preoperative radiographs. In addition, operative time, intraoperative blood loss and postoperative complications were used to evaluate the surgical management. Correlation analysis was used to determine the correlation between preoperative radiographic presentation and surgical managements. Multivariate linear regression analysis was used for determination of risk factors for surgical management.

Results

Correlation analysis showed that the median iliac angle, height of iliac crest, lumbosacral angle and intervertebral facet joint degeneration were significantly correlated with surgical managements (P<0.05). Height of iliac crest, intervertebral facet joint degeneration and lumbosacral angle were positively correlated with surgical management. Meanwhile, MIA was negatively correlated with surgical management. No significant difference was found between the IFH, ISA, ISH and surgical managements in posterior lumbar surgery (P>0.05). After multiple linear regression analysis, height of iliac crest, median iliac angle and intervertebral facet joint degeneration were independent influence factors for the single-level lumbar surgical managements.

Conclusions

Some variables measured in radiograph shows that height of iliac crest, median iliac angle and intervertebral facet joint degeneration have a potential influence on surgical managements. The lumbosacral angle was positively associated with surgical management, but it was not statistically significant in multiple linear regression analysis (P>0.05). The above measurements in plain film can reflect the surgical procedure and have some guiding implications for the operation.

Cost-utility analysis of endoscopic lumbar discectomy following a uniform clinical pathway in the Korean national health insurance system

INTRODUCTION

Full-endoscopic lumbar discectomy (FELD) is a type of minimally invasive spinal surgery for lumbar disc herniation (LDH). Sufficient evidence exists to recommend FELD as an alternative to standard open microdiscectomy, and some patients prefer FELD due to its minimally invasive nature. However, in the Republic of Korea, the National Health Insurance System (NHIS) controls the reimbursement and use of supplies for FELD, but FELD is not currently reimbursed by the NHIS. Nonetheless, FELD has been performed upon patients' request, but providing FELD for patients' sake is inherently an unstable arrangement in the absence of a practical reimbursement system. The purpose of this study was to conduct a cost-utility analysis of FELD to suggest appropriate reimbursements.

METHOD

This study was a subgroup analysis of prospectively collected data including 28 patients who underwent FELD. All patients were NHIS beneficiaries and followed a uniform clinical pathway. Quality-adjusted life years (QALYs) were assessed with a utility score using the EuroQol 5-Dimension (EQ-5D) instrument. The costs included direct medical costs incurred at the hospital for 2 years and the price of the electrode ($700), although it was not reimbursed. The costs and QALYs gained were used to calculate the cost per QALY gained.

RESULT

Patients' mean age was 43 years and one-third (32%) were women. L4-5 was the most common surgical level (20/28, 71%) and extrusion was the most common type of LDH (14, 50%). Half of the patients (15, 54%) had jobs with an intermediate level of activity. The preoperative EQ-5D utility score was 0.48±0.19. Pain, disability, and the utility score significantly improved starting 1 month postoperatively. The average EQ-5D utility score during 2 years after FELD was estimated as 0.81 (95% CI: 0.78-0.85). For 2 years, the mean direct costs were $3,459 and the cost per QALY gained was $5,241.

CONCLUSION

The cost-utility analysis showed a quite reasonable cost per QALY gained for FELD. A comprehensive range of surgical options should be provided to patients, for which a practical reimbursement system is a prerequisite.

Current Indications for Spinal Endoscopic Surgery and Potential for Future Expansion

Endoscopic spine surgery (ESS) has evolved as a safe, effective, and efficient alternative for minimally invasive spine surgery (MISS). The innovation of full-endoscopic systems makes definitive decompression surgery through different approaches feasible. The approach can be determined according to the location of the target lesion or the surgeon's preference. During the past 2 decades, ESS has expanded its indications from lumbar to cervical spines. Except for decompression, endoscopy-assisted fusion surgery is also developing. However, ESS is still evolving and has a steep learning curve. The revolution of technologies and ESS techniques will enable surgeons to treat various spinal diseases more practically. In recent years, the application of the computer-assisted navigation system and augmented reality have reformed imaging quality and interpretation. The endoscopic rhizotomy techniques have opened a new way for MISS of chronic low back pain. This review introduces the current indications of ESS and its potential future expansion.

Percutaneous Transforaminal Endoscopic Discectomy Versus Microendoscopic Discectomy for Lumbar Disk Herniation: Five-year Results of a Randomized Controlled Trial

STUDY DESIGN

A prospective randomized controlled study.

OBJECTIVE

To compare the efficacy and safety between percutaneous transforaminal endoscopic discectomy (PTED) and microendoscopic discectomy (MED).

SUMMARY OF BACKGROUND DATA

Two kinds of minimally invasive discectomy, PTED and MED, are now widely used for treating lumbar disk herniation (LDH). The long-term comparative results of these two techniques still remained uncertain.

MATERIALS AND METHODS

In this single-center, open-label, randomized controlled trial, patients were included if they had persistent signs and symptoms of radiculopathy with corresponding imaging-confirmed LDH and were randomly allocated to PTED or MED groups. The primary outcome was the score of Oswestry Disability Index (ODI) and the secondary outcomes included the score of Medical Outcomes Study 36-Item Short-Form Health Survey bodily pain (SF36-BP) and physical function (SF36-PF), European Quality of Life-Five Dimensions (EQ-5D), Visual Analog Scales for back pain (VAS-back) and leg pain (VAS-leg).

RESULTS

A total of 241 patients were accepted to enroll in our randomized controlled trial, of which 119 were randomly assigned to the PTED group, and the rest 122 were assigned to the MED group. A total of 194 out of 241 patients (80.5%) completed the five-year follow-up. PTED group was associated with shorter postoperative in-bed time and length of hospital stay. Both primary and secondary outcomes did not differ significantly between the two treatment groups at each follow-up time point. During the five-year follow-up, seven recurrent cases occurred in PTED and MED groups, respectively.

CONCLUSION

Over the five-year follow-up period, PTED and MED were both efficacious in the treatment of LDH. The long-term clinical outcomes and recurrent rates were comparable between the treatment groups. PTED represents a more minimally invasive technique with the advantages of rapid recovery.

Global Trends and Hotspots in Endoscopic Discectomy: A Study Based on Bibliometric Analysis

OBJECTIVE

With the advancement of minimally invasive spine surgery, endoscopic discectomy (ED) has become a common technique for degenerative disease of the spine. The present study aimed to explore the knowledge structure, emerging trends, and future research hotspots in this field.

METHODS

All relevant publications on ED from 2002 to 2021 were extracted from the Web of Science databases. Key bibliometric indicators, including countries/regions, institutions, authors, journals, references, and keywords were calculated and evaluated using VOSviewer and CiteSpace software.

RESULTS

A total of 1,196 articles and reviews were included for analysis. The number of publications regarding ED increased yearly. From the quality and quantity viewpoint, China, South Korea, and the United States were the major contributors in this field. The most influential institution in the field of ED was Wooridul Spine Hospital. We identified 3,488 authors, among which Lee SH had the most significant number of papers, and Ruetten S was cocited most often. <World Neurosurgery was the journal with the most papers, and Spine was the most commonly cocited journal. Keywords were stratified into 4 clusters by VOSviewer software: cluster 1 (clinical outcomes of ED in the treatment of lumbar disc herniation); cluster 2 (surgical technique of percutaneous endoscopic lumbar discectomy); cluster 3 (clinical outcomes of ED in the treatment of lumbar spinal stenosis); and cluster 4 (clinical outcomes of percutaneous endoscopic cervical discectomy). Several topics including lateral recess stenosis, spinal stenosis, and reoperation were considered as the next hotspot in ED research.

CONCLUSION

ED research has gained considerable attention over the last 2 decades. Our bibliometric findings illuminate the publication trends and research hotspots of the ED field, which may provide useful references for scholars and decision-makers interested in this field.

Transforaminal Endoscopic Lumbar Discectomy for Lumbosacral Junction Adolescent Lumbar Disc Herniation with High Iliac Crests

Objective

To investigate the clinical results of transforaminal endoscopic lumbar discectomy for lumbosacral junction adolescent lumbar disc herniation with high iliac crest.

Methods

From February 2014 to September 2020, a retrospective analysis of 96 patients less than 21 years old with intervertebral disc herniation was carried out. We enrolled 44 patients diagnosed with lumbosacral junction disc herniation with high iliac crest who required transforaminal endoscopic lumbar discectomy. Pain in the back and the lower extremity was scored on Numeric Rating Scales (NRS) scores. Patient outcomes were graded as excellent, good, fair, and poor using modified MacNab criteria. The NRS scores before and after the operation were compared using the Wilcoxon two‐sample test.

Results

There were 30 male patients and 14 females. One patient underwent repeat surgery for an intervertebral disc pseudocyst. The NRS scores decreased significantly in both early and late follow‐up evaluations (p < 0.05). At the last follow‐up, 42 patients (95.45%) had an excellent outcome, one patient (2.27%) had a good outcome, and one patient (2.27%) had a fair outcome. The overall success rate was 97.7%.

Conclusion

This study's data suggest that targeted individualized foraminoplasty can effectively overcome the lumbosacral anatomical obstacles, and transforaminal endoscopic lumbar discectomy is an effective and valid option for lumbosacral junction adolescent lumbar disc herniation with high iliac crest.

One-year clinical outcome after full-endoscopic interlaminar lumbar discectomy for isthmic lumbar spondylolisthesis: Two case reports

RATIONALE

For isthmic lumbar spondylolisthesis (ILS) associated with the removal of herniation, it remains challenging to perform less invasive and minimally disruptive procedures. Good results could potentially be obtained by further preserving the posterior elements in full-endoscopic lumbar discectomy (FESS), which is less invasive than microenscopic surgery (MES).

PATIENT CONCERNS

One patient complained of left leg pain, and another patient complained of right leg pain and low back pain.

DIAGNOSES

Two patients with ILS and Meyerding Grade 1 lumbar spondylolisthesis.

INTERVENTIONS

We performed a full-endoscopic lumbar discectomy via the interlaminar space (FESS-IL) for L5/S1 lumbar disc herniation (LDH) accompanied by isthmic lumbar spondylolisthesis. FESS-IL was performed in 2 patients with radiculopathy caused by different types of LDH using a full endoscopic system with a 4.1 mm working channel and 6.9 mm outer diameter. A 3.5-mm diameter high-speed drill was used in one patient for an upward-migrated LDH in the inner-rim of the infravertebral border. The other patient underwent minimal resection without bone resection.

OUTCOMES

The one-year clinical outcome included confirmation of pain relief and evacuation of migrated LDH on magnetic resonance imaging in all patients. There was no progression of slippage on radiography. The mean operative time was 82 min, and no complication was observed. The one-year clinical outcome demonstrated sufficient pain relief.

LESSONS THE Y

ear postoperative outcome showed improvement. We believe that FESS-IL is a viable alternative operative approach for LDH for ILS.